Angela Jeffrey, 47, of Augusta, seeks medical care at Christ Community Health Services, which caters to the poor, homeless and uninsured.

“I’m definitely a work in progress,” she said at the nonprofit health center that provides affordable primary health care to the poor, homeless and uninsured.

Like 22 percent of adults in Augusta, Jeffrey, a waitress, doesn’t have health insurance, which has kept her from getting even basic health services and preventive exams.

A high adult uninsured rate and lack of care could contribute to why Richmond County ranks poorly in categories that illustrate the health of a community, something hospitals and health providers are working to change.

University Hospital, Medical College of Georgia Hospital and Clinics and the East Central Health District teamed up to assess the needs of the community, and they found a lot of need in Augusta.

Richmond County ranked 104th in health outcomes among Georgia’s counties and 122nd in premature death. It also ranked poorly in diseases such as diabetes and related complications, said Marilyn Bowcutt, the senior vice president and chief operating officer for University.

“There wasn’t just one element that was driving the issues,” she said.

These bad results were not a surprise and were one of the reasons behind communitywide efforts, including the Greater Augusta Healthcare Network that is targeting specific problems, said Dr. Lucy Marion, the dean of Georgia Health Sciences University College of Nursing.

The needs assessments “strengthen our resolve to create programs that make a difference,” she said. Next week, one of University’s boards will be asked to approve the renovation of a building next to Christ Community Health’s clinic on D’Antignac Street for a new disease management team that will work with Christ Community Health on creating a “comprehensive medical home” for those patients that will cover a wide variety of needs, Bowcutt said. In addition to doctors and nurse practitioners, it could provide pharmacists, disease educators, nutritionists, or social workers to provide comprehensive care.

“Hopefully, we could try to even more intensely influence the total need of that patient, and see if we could keep them well,” Bowcutt said.

University has already seen success with some disease management programs. Targeting 238 congestive heart failure patients, the program cut its readmission rate to the hospital rate from 22 percent to 9.5 percent, a reduction of 61 percent. Another program targeting high-risk patients cut the readmission rate from 37 percent to 6 percent, a reduction of nearly 84 percent.

“If we could sustain that type of reduction in readmissions, we think that is part of the key to reducing some of the costs,” Bowcutt said.

Christ Community Health already tries to provide that medical home concept, said Dr. Robert Campbell, a co-founder of the clinic. Its electronic medical record, for instance, prompts the physician or nurse practitioner, based on the patient’s age and disease, to ask about related problems or preventive screenings.

He said the assessment also shows some of University’s success in working on community needs. For instance, Augusta has a higher incidence of breast cancer but a lower rate of death from it, which Campbell attributes to efforts by University and its physicians to get women to mammograms, such as through its Mobile Mammography Unit that provides more convenient screenings.

“They do that all over the community,” he said. “I can’t draw a 1-to-1 correlation between those two things but we have a high incidence and a low death rate. And I think it is partially because of the responsiveness of our community.”

Though the clinical system at GHSU provides more than $90 million in indigent and charity care, that doesn’t take into account all of the volunteer efforts its faculty and students provide in the community, Marion said, which might be part of future assessments.

“We have not added it all up yet,” she said. But it will likely take more partnerships and combined efforts to really address it. “It will take the community to move that needle,” Marion said.

Christ Community Health hopes to add two physicians this year, which would increase its capacity to do more, Campbell said.

“We will grow as our resources allow to try to push even harder to develop that medical home for more and more patients in the areas of our community that have the heaviest need,” he said.

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